stroke, head trauma and conciousness
DESCRIPTION
Stroke, Head Trauma and conciousness. Amy Wood, Haddy Cosh, Vishal Chauhan, Asfand Baig , Stewart O’Conner. Definition. Definition. a syndrome of rapid onset of cerebral deficit (usually focal) Lasting > 24 hours or leading to death and no cause apparent other than a vascular one. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/1.jpg)
Stroke, Head Trauma and conciousness
Amy Wood, Haddy Cosh, Vishal Chauhan, Asfand Baig, Stewart O’Conner
![Page 2: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/2.jpg)
Definition
![Page 3: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/3.jpg)
Definition a syndrome of rapid onset of cerebral
deficit (usually focal) Lasting > 24 hours or leading to death and
no cause apparent other than a vascular one
![Page 4: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/4.jpg)
Stroke Risk Factors Non Modifiable
Modifiable
![Page 5: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/5.jpg)
Stroke Risk Factors Non Modifiable
Age Male FHx Race – black/
hispanic
Modifiable HT IHD AF DM Hypercholesterola
emia Smoking Alcohol
![Page 6: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/6.jpg)
Types
![Page 7: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/7.jpg)
Types Ischaemia/ embolism causing cerebral infarct
– 80%
Intracebral Haemorrhagic – 15%
![Page 8: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/8.jpg)
Causes -Haemorrhagic
![Page 9: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/9.jpg)
Causes -Haemorrhagic Ruptured aneurysm Trauma (subarachnoid/intracerebral) Dissection (carotid/vertebral)
![Page 10: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/10.jpg)
Causes - Ischaemic
![Page 11: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/11.jpg)
Causes - Ischaemic Cerebral Thrombosis Cerebral Emboli
Give examples Lacunar
![Page 12: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/12.jpg)
Symptoms - General
![Page 13: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/13.jpg)
Symptoms - General Weakness/Paralysis or numbness on
contralateral side Vertigo/dizziness Headache Visual loss/blurred vision Faintness Confusion Speech problems Difficulty swallowing Cognitive problems Memory problems Consciousness alterations BUT…DEPENDS ON SITE
![Page 14: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/14.jpg)
Stroke Syndromes
![Page 15: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/15.jpg)
Stroke Syndromes TACS - Total Anterior Circulation Syndrome PACS - Partial Anterior Circulation Syndrome LACS - Lacunar Syndrome POCS - Posterior Circulation Syndrome
![Page 16: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/16.jpg)
What are the differences between them?
![Page 17: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/17.jpg)
Syndrome Symptoms Artery
TACS Higher DysfunctionsDysphasiasVisuospatial problemsHomonymous HemianopiaMotor/Sensory Deficits
ICA, MCA, (ACA)
PACS 2/3 Similar to TACIPartial motor/sensory deficitsHigher dysfunction alone
MCA, (ACA)
LACS Pure Motor or Sensory or Sensorimotor lossAtaxic Hemiparesis
Small vessels (Perforating arteries)
POCS Cranial nerve palsy & contralateral motor/sensory deficitBilateral motor or sensory deficitCerebellar signsEye Movement deficits/isolated homonymous
hemianopia
Vertebral
PCA
![Page 18: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/18.jpg)
Extras - watershedsSyndrome Symptoms Artery
Watershed ACA-MCA
"Man-in-a-Barrel" SyndromeAphasia
Internal Carotid Artery occlusion
Watershed MCA-PCA
Visual Processing ICA
Susceptibility to ischaemia:• Systemic BP drop• ACA-MCA occlusion of carotid
![Page 19: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/19.jpg)
TIA
![Page 20: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/20.jpg)
TIA Sudden focal deficit – usually only a few
seconds Presentation very similar to stroke Amaurosis fugax??
<24 hours with complete recovery
Issue: after 1 hour ischaemic damage has already occurred
High risk of recurrence and full stroke
![Page 21: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/21.jpg)
Causes- TIA
![Page 22: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/22.jpg)
Causes- TIACarotid artery insufficiency – 80%Veterbrobasilar Insufficiency – 20%
Circle of Willis – collateral supplies
![Page 23: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/23.jpg)
Management1. Assessment/ diagnosis
Location Subtype Cause
2. Acute intervention 3. Secondary prevention
Reduce risk factors
![Page 24: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/24.jpg)
Assessment and Diagnosis
![Page 25: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/25.jpg)
Assessment: Diagnosis Clinically usually
FAST
Imaging - <3hrs CT
Available Exclude haemorrhage
MRI If brainstem or cerebellar symptoms
![Page 26: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/26.jpg)
Urgent CT required
![Page 27: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/27.jpg)
Acute intervention
![Page 28: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/28.jpg)
Acute intervention Admit to Acute Stroke Unit for assessment
Iscahaemic – Thrombolysis rTPA within 3 hrs of symptoms
Haemorragic – emergency surgery
![Page 29: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/29.jpg)
Antiplatelet drugs (Aspirin 150-300mg) if infarct Contraindicated if haemorrhage!!
Monitor/prevent complications Physiological monitoring for first 72 hours to
maintain CO and supply to brain HR, Temperature, BP, O2 sats, Blood sugar, ECG
Acute intervention
![Page 30: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/30.jpg)
Complications
![Page 31: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/31.jpg)
Complications Post-stroke pain/thalamic pain
1 week- 6 months after stroke Anywhere in spinothalamic system Contralateral side referral of pain Burning + sharp Hyperalgesia & Allodynia
Treat as for neuropathic pain TCAs
![Page 32: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/32.jpg)
![Page 33: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/33.jpg)
Layers of the brain
a) Pia materb) Arachnoid mater c) Dura mater d) Superior sagittal
venous sinus e) Skull f) Falx celebri g) Subarachnoid space
![Page 34: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/34.jpg)
Pia
Arachnoid
Dura
Subarachnoid – arteries
Subdural – Bridging veins
Epidural – Meningeal arteries
![Page 35: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/35.jpg)
Normal CT
Usually going to be symmetrical Ventricles symmetrical and equally full
![Page 36: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/36.jpg)
Midline Shift Coup injury –
injury on same side of force
Contra coup– injury on the opposite side on injury
If you see midline shift, you have a high pressure situation
![Page 37: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/37.jpg)
Case 1 Young lady hit on the side of head by a glass at a gig,
seemed to recover , Found slumped 50 minutes later Ix?
CT/MRI, x-ray if fracture Where may she have been hit?
Pterion What bones converge here?
frontal, parietal, sphenoid, temporal What does this area cover?
Middle meningeal artery Type of intracranial haemorrhage?
extradural (epi) Type of blood characterises this?
Arterial Why passed out?
raised ICP Rx
surgical
![Page 38: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/38.jpg)
Extradural haematoma:
Midline shift
Lenticular shape
This can be middle meningeal artery – pterion bone breaks
Cerebral perfusion pressure = mean arterial pressure – ICP
Extradural haematoma you give Mannitol – 100mL at 20% Diuretic
![Page 39: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/39.jpg)
Case 2 Old alcoholic man had a fall in the park now noticed to be very
drowsy with low consciousness Ix:
CT/MRI Likely haematoma?
Subdural Other symptoms?
Headache, confusion, N/V, tinnitus, speech and visual problems, dizziness, weakness
Where is the bleed likely to be? bridging veins
Type of blood? venous
Rx depends on size + growth rate: often conservative (body reabsorbs), sometimes burr-hole drainage
Acute or Chronic
![Page 40: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/40.jpg)
Subdural Haematoma:
Runs along the surface of the brain, underneath the dura
Depending on the GCS score of the patient you may need to remove it
Midline shift
![Page 41: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/41.jpg)
![Page 42: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/42.jpg)
Subarachnoid Haemorrhage Sudden onset severe
headache, often at the back of the head, Neck stiffness, Impaired consciousness (drowsiness / coma), Cranial nerve signs, Hemiplegia
The bleeding occurs as the result of rupture of aneurysm (80%) and AV malformations (15%) or trauma
![Page 43: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/43.jpg)
Contusion (bruise)
Intra- axial As bruise swells, pressure goes up – all features
of raised ICP (coma) If you remove them you need to do a craniotomy
![Page 44: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/44.jpg)
Diffuse Axonal InjuryRTAs / shaken baby syndrome
If a rotational force is applied, the axons are damaged and you can have damage very far away from the original injury – diffuse axonal injury
Small contusions all over the brain
The worse it looks on the CT scan, the worse the injury in the patient – especially if you see an injury in the brainstem
DAI doesn’t look as bad on CT as some of the other ones, but can be much worse
![Page 45: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/45.jpg)
Le fort Fractures
![Page 46: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/46.jpg)
Blow-Out Fractures
![Page 47: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/47.jpg)
With a mass lesion why do you not get an immediate loss of consciousness?
![Page 48: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/48.jpg)
Due to an ability to Compensate! Intra cranial vol = vol CSF + vol Brain + vol
blood + vol Mass lesion Skull can’t expand Compensation – 10-20 ml CSF in to lumbar
cisterns Compensation exceeded Increase in ICP
herniation
![Page 49: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/49.jpg)
What are the 3 key symptoms of raised ICP?
Papilloedema
Headache
Nausea and Vomiting
![Page 50: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/50.jpg)
Label diagram
![Page 51: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/51.jpg)
Name two areas of the brain that can be damaged, leading to loss of consciousness?
Compression of reticular formation from herniation
Large damage to cortical regions
![Page 52: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/52.jpg)
How unconscious are they?
What is the main tool that we use to measure this?
![Page 53: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/53.jpg)
Glasgow Coma scale
![Page 54: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/54.jpg)
“Patient has Glasgow coma score of 9”
What’s wrong with this?
![Page 55: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/55.jpg)
It’s more useful to say:
GCS = V1 E3 M5V3 E3 M3 etc.
They are different situations that may need managing differently
![Page 56: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/56.jpg)
Three indicators of change of brain function in the unconscious patient?
Reaction to painful stimulus – (part of Glasgow Coma scale)
Vestibulo-ocular reflex E.g Caloric test, doll’s head
test
Size and reaction of pupils
![Page 57: Stroke, Head Trauma and conciousness](https://reader036.vdocuments.net/reader036/viewer/2022062316/568166ec550346895ddb366a/html5/thumbnails/57.jpg)
What are the three components of consciousness? Alertness - upper brainstem reticular formation
- wakefulness
Awareness - cerebral cortex state of awareness and interaction with environment
Attention - limbic system and frontoparietal association areas - affect, mood, attention, motivation pay attention to